Question 1:
A 29-year-old female who is 34 weeks pregnant is referred to your office due to abnormal liver tests seen on routine labs. Labs are notable for ALP of 225, AST 85, ALT 88, and platelets of 175,00. Bilirubin and INR are within normal limits. Her vital signs are normal. On exam, she has a non-tender gravid abdomen, and her skin is not jaundiced but is notable for linear excoriations on her bilateral arms. When prompted, she reports experiencing worsening pruritus. After visit labs show persistent ALP, AST, and ALT elevations, non-reactive Hepatitis A, B, and C serologies, a normal anti-mitochondrial antibody, negative anti-smooth muscle Ab, urinalysis without protein, and total serum bile acids of 42 micromol/L. Ultrasound was without biliary ductal dilation.
What is the next best step in management?
A) MRCP is needed for further biliary tree evaluationB) Liver biopsy since a definitive diagnosis has not been madeC) Emergent deliveryD) Trial of ursodiol and trend bile acids to determine delivery timingSubmit
Correct Answer:
D) Trial of ursodiol and trend bile acids to determine delivery timing
This patient has intrahepatic cholestasis of pregnancy, which is diagnosed with a combination of clinical findings of new onset pruritus in the 2nd/3rd trimesters, elevated serum bile acids, and negative serologies for other causes of abnormal liver chemistries. No further diagnostics are needed (Choices A and B). While there is no risk to the mother with intrahepatic cholestasis of pregnancy (ICP), there is an increased risk of fetal demise with ICP. However, this is typically with much higher bile acid levels (> 100 micromol/L). Even with higher bile acids, delivery is often delayed until after 36 weeks gestation to allow for further fetal development. Ursodiol is routinely prescribed at 10-15mg/kg maternal body weight and can reduce pruritus. However, evidence regarding effectiveness in preventing adverse fetal outcomes is controversial. This patient does not have any pregnancy-related liver disease that necessitates emergent delivery (e.g. HELLP, acute fatty liver of pregnancy, or preeclampsia with severe features).
KEY POINT: Intrahepatic cholestasis of pregnancy should be managed with a trial of ursodiol for symptoms and close, serial monitoring of serum bile acids. High serum bile acid levels pose a risk to the developing fetus and therefore help determine optimal delivery timing, which should be a conversation with OB/Gyn.
AUTHOR, TOPIC: MO, liver disease in pregnancy